Marine Machinery Breakdown Claim Form
Policy Number
Insured Name
Contact Details
Vessel Name
IMO Number
Type of Machinery
Breakdown Location
Date & Time of Breakdown
Breakdown Details
Description of Breakdown
Suspected Cause
Estimated Repair Cost
Steps Taken After Breakdown
Repair Details
Name of Repairer
Repair Location
Date of Repair
Repair Description
Declaration
I hereby declare that the information provided is true and correct to the best of my knowledge.
Signature
Date